Diabetes Mellitus

By:
Emad Qassim Khaleel
Ghassan Mahmood khalaf
Firas Khalaf Eido

? What is diabetes
Diabetes mellitus (DM) is a group
of diseases characterized by high
levels of blood glucose resulting
from defects in insulin
production, insulin action, or
. both
The term diabetes mellitus
describes a metabolic disorder of
multiple aetiology characterized
by chronic hyperglycaemia with
disturbances of carbohydrate,
fat and protein metabolism
resulting from defects in insulin
.secretion, insulin action, or both

Diabetes
Diabetes mellitus may present with characteristic
symptoms such as thirst, polyuria, blurring of vision, and
. weight loss
In its most severe forms, ketoacidosis or a nonketotic
hyperosmolar state may develop and lead to stupor,
. coma and, in absence of effective treatment, death
Often symptoms are not severe, or may be absent, and
consequently hyperglycaemia sufficient to cause
pathological and functional changes may be present for
.a long time before the diagnosis is made

Insulin
is a hormone,
produced by beta
cells in the
pancrease
Insulin work as key in the
blood first it breakdown the
sugar to glucose then make it
to enter the cell because the
glucose is the source of
energy

When there's no
Insulin or produced
few amount it will be
no key in the blood and
the sugar will collected
in the blood

Burden of Diabetes
The development of diabetes is projected to reach
. pandemic proportions over the next10-20 years
International Diabetes Federation (IDF) data indicate that by
the year 2025, the number of people affected will reach
.333 million 90% of these people will have Type 2 diabetes
In most Western societies, the overall prevalence has
reached 4-6%, and is as high as 10-12% among 60-70-year.old people
The annual health costs caused by diabetes and its
complications account for around 6-12% of all health-care
.expenditure

Diabetes Long-term Effects

The longterm effects of diabetes mellitus include
progressive development of the specific complications
of retinopathy with potential blindness, nephropathy
that may lead to renal failure, and/or neuropathy with
risk of foot ulcers, amputation, Charcot joints, and
features of autonomic dysfunction, including sexual
. dysfunction
People with diabetes are at increased risk of
cardiovascular, peripheral vascular and cerebrovascular
.disease

Types of Diabetes
Type 1 Diabetes Mellitus
Type 2 Diabetes Mellitus
Gestational Diabetes
Other types:
LADA
MODY (maturity-onset diabetes of youth)

Secondary Diabetes Mellitus

Type 1 diabetes
Was previously called insulin-dependent
diabetes mellitus (IDDM) or juvenile-onset
. diabetes
Type 1 diabetes develops when the bodys
immune system destroys pancreatic beta
cells, the only cells in the body that make the
hormone insulin that regulates blood
. glucose
This form of diabetes usually strikes children
and young adults, although disease onset
. can occur at any age
Type 1 diabetes may account for 5% to 10%
. of all diagnosed cases of diabetes
Risk factors for type 1 diabetes may include
autoimmune, genetic, and environmental
.factors

Type 2 diabetes
Was previously called non-insulindependent diabetes mellitus (NIDDM) or
. adult-onset diabetes
Type 2 diabetes may account for about 90%
. to 95% of all diagnosed cases of diabetes
It usually begins as insulin resistance, a
disorder in which the cells do not use
insulin properly. As the need for insulin
rises, the pancreas gradually loses its
. ability to produce insulin
Type 2 diabetes is associated with older
age, obesity, family history of diabetes,
history of gestational diabetes, impaired
glucose metabolism, physical inactivity, and
. race/ethnicity
African Americans, Hispanic/Latino
Americans, American Indians, and some
Asian Americans and Native Hawaiians or
Other Pacific Islanders are at particularly
. high risk for type 2 diabetes
Type 2 diabetes is increasingly being
.diagnosed in children and adolescents

Gestational diabetes
A form of glucose intolerance that is diagnosed in some
. women during pregnancy
Gestational diabetes occurs more frequently among
African Americans, Hispanic/Latino Americans, and
American Indians. It is also more common among obese
. women and women with a family history of diabetes
During pregnancy, gestational diabetes requires treatment
to normalize maternal blood glucose levels to avoid
. complications in the infant
After pregnancy, 5% to 10% of women with gestational
. diabetes are found to have type 2 diabetes
Women who have had gestational diabetes have a 20% to
.50% chance of developing diabetes in the next 5-10 years

Other types of DM
Other specific types of diabetes result from specific
genetic conditions (such as maturity-onset diabetes of
youth), surgery, drugs, malnutrition, infections, and
. other illnesses
Such types of diabetes may account for 1% to 5% of all
. diagnosed cases of diabetes

LADA
Latent Autoimmune Diabetes in Adults (LADA) is a form
of autoimmune (type1 diabetes) which is diagnosed in
individuals who are older than the usual age of onset of
. type 1 diabetes
Alternate terms that have been used for "LADA" include
Late-onset Autoimmune Diabetes of Adulthood, "Slow
Onset Type 1" diabetes, and sometimes also "Type 1.5
Often, patients with LADA are mistakenly thought to
have type2 diabetes, based on their age at the time
. of diagnosis

LADA (cont.)

LADA (cont.)
About 80% of adults apparently with recently
diagnosed Type 2 diabetes but with GAD autoantibodies (i.e. LADA) progress to insulin
.requirement within 6 years
The potential value of identifying this group
at high risk of progression to insulin
:dependence includes
the avoidance of using metformin treatment
the early introduction of insulin therapy

MODY
MODY Maturity Onset Diabetes of the Young
MODY is a monogenic form of diabetes with an autosomal dominant
:mode of inheritance
Mutations in any one of several transcription factors or in the enzyme
glucokinase lead to insufficient insulin release from pancreatic -cells,
.causing MODY
.Different subtypes of MODY are identified based on the mutated gene

Originally, diagnosis of MODY was based on presence of non-ketotic

hyperglycemia in adolescents or young adults in conjunction with a
.family history of diabetes
However, genetic testing has shown that MODY can occur at any age
.and that a family history of diabetes is not always obvious

MODY (cont.)

MODY (cont.)
Within MODY, the different subtypes can essentially
be divided into 2 distinct groups: glucokinase MODY
and transcription factor MODY, distinguished by
characteristic phenotypic features and pattern on
. oral glucose tolerance testing
Glucokinase MODY requires no treatment, while
transcription factor MODY (i.e. Hepatocyte nuclear
factor -1alpha) requires low-dose sulfonylurea
therapy and PNDM (caused by Kir6.2 mutation)
.requires high-dose sulfonylurea therapy

Secondary DM
: Secondary causes of Diabetes mellitus include
, Acromegaly
, Cushing syndrome
, Thyrotoxicosis
Pheochromocytoma
, Chronic pancreatitis
Cancer
:Drug induced hyperglycemia

Atypical Antipsychotics - Alter receptor binding characteristics, leading to increased insulin

.resistance
.Beta-blockers - Inhibit insulin secretion
Calcium Channel Blockers - Inhibits secretion of insulin by interfering with cytosolic calcium
.release
.Corticosteroids - Cause peripheral insulin resistance and gluconeogensis
.Fluoroquinolones - Inhibits insulin secretion by blocking ATP sensitive potassium channels
Naicin - They cause increased insulin resistance due to increased free fatty acid
.mobilization
.Phenothiazines - Inhibit insulin secretion
.Protease Inhibitors - Inhibit the conversion of proinsulin to insulin
Thiazide Diuretics - Inhibit insulin secretion due to hypokalemia. They also cause increased
.insulin resistance due to increased free fatty acid mobilization

Diagnosis of

Values of Diagnosis of Diabetes

Mellitus

Prevention or delay of diabetes:

Life style modification
Research studies have found that lifestyle changes
can prevent or delay the onset of type 2 diabetes
. among high-risk adults
These studies included people with IGT and other
.high-risk characteristics for developing diabetes
Lifestyle interventions included diet and moderateintensity physical activity (such as walking for 2 1/2
. hours each week)
In the Diabetes Prevention Program, a large
prevention study of people at high risk for
diabetes, the development of diabetes was reduced
. 58% over 3 years

Prevention or delay of diabetes:

Medications
Studies have shown that medications have been successful in
. preventing diabetes in some population groups
In the Diabetes Prevention Program, people treated with the
drug metformin reduced their risk of developing diabetes by 31%
. over 3 years
Treatment with metformin was most effective among younger,
heavier people (those 25-40 years of age who were 50 to 80
pounds overweight) and less effective among older people and
. people who were not as overweight
Similarly, in the STOP-NIDDM Trial, treatment of people with IGT
with the drug acarbose reduced the risk of developing diabetes
. by 25% over 3 years
Other medication studies are ongoing. In addition to preventing
progression from IGT to diabetes, both lifestyle changes and
medication have also been shown to increase the probability of
. reverting from IGT to normal glucose tolerance

Management of Diabetes Mellitus

Management of DM
:The major components of the treatment of diabetes are

A. Diet
Diet is a basic part of management in
every case. Treatment cannot be
effective unless adequate attention is
.given to ensuring appropriate nutrition

:Dietary treatment should aim at

ensuring weight control*
providing nutritional requirements*
allowing good glycaemic control with
blood glucose levels as close to
normal as possible
correcting any associated blood lipid
abnormalities

A. Diet (cont.)
The following principles are recommended as dietary
:guidelines for people with diabetes
Dietary fat should provide 25-35% of total intake of calories
but saturated fat intake should not exceed 10% of total
energy. Cholesterol consumption should be restricted and
.limited to 300 mg or less daily
Protein intake can range between 10-15% total energy (0.8-1
g/kg of desirable body weight). Requirements increase for
children and during pregnancy. Protein should be derived from
.both animal and vegetable sources
Carbohydrates provide 50-60% of total caloric content of the
.diet. Carbohydrates should be complex and high in fibre
Excessive salt intake is to be avoided. It should be particularly
restricted in people with hypertension and those with
.nephropathy

Exercise
Physical activity promotes weight
reduction and improves insulin sensitivity,
.thus lowering blood glucose levels
Together with dietary treatment, a
programme of regular physical activity
and exercise should be considered for
each person. Such a programme must be
tailored to the individuals health status
. and fitness
People should, however, be educated
about the potential risk of hypoglycaemia
.and how to avoid it

Oral Anti-Diabetic Agents

There are currently four classes of oral anti:diabetic agents
i. Biguanides
ii. Insulin Secretagogues Sulphonylureas
iii. Insulin Secretagogues Nonsulphonylureas
iv. -glucosidase inhibitors
v. Thiazolidinediones (TZDs)

Oral Agent Monotherapy

:As first line therapy
.Obese type 2 patients, consider use of metformin, acarbose or TZD
Non-obese type 2 patients, consider the use of metformin or insulin
secretagogues
Metformin is the drug of choice in overweight/obese patients. TZDs and
.acarbose are acceptable alternatives in those who are intolerant to metformin
If monotherapy fails, a combination of TZDs, acarbose and metformin is
recommended. If targets are still not achieved, insulin secretagogues may be
added

Insulin Therapy
:Short-term use
Acute illness, surgery, stress and emergencies
Pregnancy
Breast-feeding
Insulin may be used as initial therapy in type 2 diabetes
in marked hyperglycaemia
Severe metabolic decompensation (diabetic ketoacidosis, hyperosmolar
nonketotic coma, lactic acidosis, severe hypertriglyceridaemia)

:Long-term use
If targets have not been reached after optimal dose of combination therapy or
BIDS, consider change to multi-dose insulin therapy. When initiating this,insulin
secretagogues should be stopped and insulin sensitisers e.g. Metformin or TZDs,
.can be continued

Self-Care
Patients should be educated to practice self-care.
This allows the patient to assume responsibility
and control of his / her own diabetes
:management. Self-care should include

Blood glucose monitoring

Body weight monitoring

Foot-care

Personal hygiene
Healthy lifestyle/diet or physical activity

Identify targets for control

Stopping smoking

Thank you
any
Question
about

References
National Diabetes Fact Sheet 2003, DEPARTMENT OF HEALTH AND
HUMAN SERVICES Centres for Disease Control and Prevention
World Health Organization. Definition, Diagnosis and Classification of
Diabetes Mellitus and its Complications. Report of WHO. Department
of Non-communicable Disease Surveillance. Geneva 1999
Academy of Medicine. Clinical Practice Guidelines. Management of
type 2 diabetes mellitus. MOH/P/PAK/87.04(GU), 2004
NHS. Diabetes - insulin initiation - University Hospitals of Leicester
NHS Trust Working in partnership with PCTs across Leicestershire and
. Rutland, May 2008